HESI Health Assessment BSN 246: Questions With
Accurate Answers (Boost Your Grades)
An 18 year-old presents to the emergency department with "headache."
Which of these assessment findings alerts the nurse to recent opioid use?
Pupillary constriction
Hallucinations.
Fever.
Tachypnea. Right Ans - A- constricted pupils are a sign of recent opioid use,
the rest are withdrawals
While collecting the pulse on a 26 year-old client, the nurse notes that the
heart rate seems to speed up and then slow down in accordance with
respirations. The pulse is counted at 80 beats per minute. What should the
nurse do next?
Obtain orthostatic vital signs.
Notify the physician.
Document "sinus arrhythmia."
Use a doppler to confirm the finding. Right Ans - C
An elderly client with pneumonia is being treated in the intensive care unit
(ICU). He is acutely agitated, restless, and disoriented. The nurse documents
his level of consciousness as:
Manic.
Demented.
Drowsy.
,Delirious. Right Ans - D
The nurse is assessing a newborn infant. How should the nurse measure the
heart rate (HR)?
Palpate the radial pulse for 15 seconds and multiply by four.
Palpate the brachial pulse for 30 seconds and multiply by two.
Auscultate the apical site for 60 seconds.
Apply a pulse oximeter to obtain both the HR and SpO2. Right Ans - C
A 28 year-old is brought to the emergency department. He is disoriented and
hallucinating, and vital signs are elevated. The nurse suspects that the patient
is experiencing withdrawal symptoms from which substance?
Alcohol.
Cocaine.
Cannabis.
Opiates. Right Ans - A- hallucinations and delirium are commonly seen w
alcohol withdrawal
When evaluating the temperature of older adults, the nurse should remember
which aspect about an older adult's body temperature?
Fever is a reliable sign of infection in older adults.
The older adult's body temperature varies widely because of the thinner
subcutaneous layer.
There are no differences in temperature between a young and old adult.
Older adults body temperature runs lower than that of an adult. Right Ans -
D
,Which error may result in a falsely low blood pressure (BP) reading?
The patient has a full bladder.
The arm is held above the level of the heart.
The cuff size is too small for the client.
The BP cuff is wrapped loosely around the arm. Right Ans - B- at heart level
During a general survey of a post-operative patient, the nurse notes that the
patient's eyes are closed but they temporarily open with loud verbal stimulus
and a gentle shake to the shoulder. The nurse documents his level of
consciousness as:
Alert.
Somnolent.
Stuporous.
Obtunded. Right Ans - D
A 46-year-old male presents to the Emergency Department with syncope. He
says his cardiologist recently placed him on a new medication for his blood
pressure (BP). What should the nurse do first?
Obtain orthostatic vital signs.
Educate the patient on homeopathic methods to control his BP.
Administer a fluid bolus.
Advise the patient to stop taking this medication. Right Ans - A
As a mandatory reporter, the nurse notifies the authorities with which of the
following?
, Suspicion of child or elder abuse/neglect.
Proof of substance abuse in minors.
Any bruising on a child or older adult.
Proof of intimate partner violence. Right Ans - A
The nurse is caring for a patient with chronic lower back pain. The nurse
knows that the most reliable indicator of pain in this client is:
The patient is reporting "6/10" pain.
The patient is refusing to get out of bed.
The patient is refusing to eat breakfast.
The patient's heart rate is 90 beats per minute. Right Ans - A
Which of the following actions should the nurse take to ensure an accurate
blood pressure (BP) reading?
Ensure the width of the BP cuff is equal to 80% of the arm circumference.
Ensure the client's back is supported and feet are flat on the ground.
Take two BP readings 20 seconds apart.
Ensure that the patient's arm is above heart level. Right Ans - B
The patient's arm should be supported at heart level. Separate BP readings
may need to be taken, but not one right after the other. The length of the BP
bladder should equal 80% of the arm circumferen
The nurse obtains which piece of data during the general survey?
Client is alert and calm.
Client's heart rate is 80 beats per minute.
Accurate Answers (Boost Your Grades)
An 18 year-old presents to the emergency department with "headache."
Which of these assessment findings alerts the nurse to recent opioid use?
Pupillary constriction
Hallucinations.
Fever.
Tachypnea. Right Ans - A- constricted pupils are a sign of recent opioid use,
the rest are withdrawals
While collecting the pulse on a 26 year-old client, the nurse notes that the
heart rate seems to speed up and then slow down in accordance with
respirations. The pulse is counted at 80 beats per minute. What should the
nurse do next?
Obtain orthostatic vital signs.
Notify the physician.
Document "sinus arrhythmia."
Use a doppler to confirm the finding. Right Ans - C
An elderly client with pneumonia is being treated in the intensive care unit
(ICU). He is acutely agitated, restless, and disoriented. The nurse documents
his level of consciousness as:
Manic.
Demented.
Drowsy.
,Delirious. Right Ans - D
The nurse is assessing a newborn infant. How should the nurse measure the
heart rate (HR)?
Palpate the radial pulse for 15 seconds and multiply by four.
Palpate the brachial pulse for 30 seconds and multiply by two.
Auscultate the apical site for 60 seconds.
Apply a pulse oximeter to obtain both the HR and SpO2. Right Ans - C
A 28 year-old is brought to the emergency department. He is disoriented and
hallucinating, and vital signs are elevated. The nurse suspects that the patient
is experiencing withdrawal symptoms from which substance?
Alcohol.
Cocaine.
Cannabis.
Opiates. Right Ans - A- hallucinations and delirium are commonly seen w
alcohol withdrawal
When evaluating the temperature of older adults, the nurse should remember
which aspect about an older adult's body temperature?
Fever is a reliable sign of infection in older adults.
The older adult's body temperature varies widely because of the thinner
subcutaneous layer.
There are no differences in temperature between a young and old adult.
Older adults body temperature runs lower than that of an adult. Right Ans -
D
,Which error may result in a falsely low blood pressure (BP) reading?
The patient has a full bladder.
The arm is held above the level of the heart.
The cuff size is too small for the client.
The BP cuff is wrapped loosely around the arm. Right Ans - B- at heart level
During a general survey of a post-operative patient, the nurse notes that the
patient's eyes are closed but they temporarily open with loud verbal stimulus
and a gentle shake to the shoulder. The nurse documents his level of
consciousness as:
Alert.
Somnolent.
Stuporous.
Obtunded. Right Ans - D
A 46-year-old male presents to the Emergency Department with syncope. He
says his cardiologist recently placed him on a new medication for his blood
pressure (BP). What should the nurse do first?
Obtain orthostatic vital signs.
Educate the patient on homeopathic methods to control his BP.
Administer a fluid bolus.
Advise the patient to stop taking this medication. Right Ans - A
As a mandatory reporter, the nurse notifies the authorities with which of the
following?
, Suspicion of child or elder abuse/neglect.
Proof of substance abuse in minors.
Any bruising on a child or older adult.
Proof of intimate partner violence. Right Ans - A
The nurse is caring for a patient with chronic lower back pain. The nurse
knows that the most reliable indicator of pain in this client is:
The patient is reporting "6/10" pain.
The patient is refusing to get out of bed.
The patient is refusing to eat breakfast.
The patient's heart rate is 90 beats per minute. Right Ans - A
Which of the following actions should the nurse take to ensure an accurate
blood pressure (BP) reading?
Ensure the width of the BP cuff is equal to 80% of the arm circumference.
Ensure the client's back is supported and feet are flat on the ground.
Take two BP readings 20 seconds apart.
Ensure that the patient's arm is above heart level. Right Ans - B
The patient's arm should be supported at heart level. Separate BP readings
may need to be taken, but not one right after the other. The length of the BP
bladder should equal 80% of the arm circumferen
The nurse obtains which piece of data during the general survey?
Client is alert and calm.
Client's heart rate is 80 beats per minute.
